Adenomyosis Jamie A. M. Massie MD Ruth B. Lathi MD Lynn M.

Westphal MD Basics Description The presence of endometrial glands and stroma within the uterine musculature. Age-Related actors !rimarily occurs in women "#$%# years old &pidemiology 'ncidence difficult to determine as diagnosis (ased on microscopic e)amination of uterus and many patients are asymptomatic !ossi(ly affects up to *%$+#, of women

Less common in nulliparous women

Ris- actors Age ."# years /istory of uterine surgery

/istory of child(earing0 although increasing parity not associated with increased ris- of disease

!athophysiology 1n-nown0 (ut theories include2 &ndomyometrial in3agination of the endometrium Acti3ation of m4llerian rests within uterine musculature Associated 5onditions Leiomyomas &ndometriosis

&ndometrial polyps

Diagnosis 6igns and 6ymptoms /istory !el3ic pain &)cessi3ely hea3y or prolonged menstrual (leeding

6econdary dysmenorrhea2 !ain that (egins after the start of menstrual flow 7*8" of affected women are asymptomatic.

Re3iew of 6ystems Lightheadedness8Di99iness !rimary complaint not :' related

Denies fe3er8chills

Denies anore)ia or nausea83omiting A(sence of urinary fre;uency or dysuria A(sence of purulent 3aginal discharge

!hysical &)am 6ymmetrically enlarged and (oggy uterus 1terus soft and tender

1terus is freely mo(ile <o uterosacral nodularity <o adne)al masses 5onfirmation of clinical diagnosis can only (e made (y pathologic e3aluation of uterus at time of hysterectomy. :ross appearance2
o o

Tests

Diffusely enlarged uterus with thic-ened myometrium Areas of focal in3ol3ement may appear as circumscri(ed adenomyomas.

/istologic appearance2
o

&ndometrial tissue within the myometrium0 at least * low-power field from the endomyometrial =unction >one of endometrial hyperplasia surrounds the adenomatous tissue

La(s /ysterectomy specimen to pathology 'maging T?6 shows generally enlarged uterus2 o Diffusely enlarged uterus with thic-ened uterine wall

MR' is diagnostic modality of choice2

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Areas of decreased signal intensity in affected areas 5an usually distinguish (etween uterine fi(roids and adenomyomas @focal areas of adenomyosisA

Differential Diagnosis 1terine leiomyomata &ndometrial polyps

1terine malignancy !rimary dysmenorrhea

&ndometriosis 'nterstitial cystitis !el3ic adhesi3e disease !'D B3arian torsion &ctopic pregnancy

Management :eneral Measures Bnly definiti3e treatment for adenomyosis is total hysterectomy0 howe3er0 treatment is (ased on patient age and desire for future fertility. Medication @DrugsA 'n women who choose to maintain their fertility or ha3e other contraindications to surgical management0 medical treatments can (e utili9ed. <6A'Ds

B5!s Medro)yprogesterone acetate @Depo !ro3eraA :nR/ agonist2

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Duration of therapy should (e limited to C months if used alone. Add-(ac- therapy with progestins or low-dose B5!s may (e utili9ed to minimi9e (one loss and limit 3asomotor symptoms.

6urgery Total hysterectomy0 with o3arian conser3ation2 o A(dominal or laparoscopic-assisted approach

o

?aginal hysterectomy indicated if the uterus is not significantly enlarged

1terine artery em(oli9ation2

o

&ndomyometrial a(lation is useful in patients who desire conser3ati3e surgical management. Laparoscopic myometrial electrocoagulation &)cision of adenomyomas

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ollowup Disposition 'ssues for Referral 6uspicion of uterine malignancy prior to surgical inter3ention or at time of planned hysterectomy necessitates referral to a gynecologic oncologist.

!atients with adenomyosis and infertility should (e referred to reproducti3e endocrinologist or gynecologist with e)pertise in infertility.

!.C% !rognosis /ysterectomy pro3ides definiti3e resolution of symptoms. Medical therapies result in short-term impro3ement0 (ut symptoms often recur after discontinuation of therapy.

5onser3ati3e surgical inter3entions0 such as endomyometrial a(lation or uterine artery em(oli9ation0 may ha3e (enefit in patients with (leeding as primary complaint.

!atient Monitoring !atients with se3ere menorrhagia are at ris- of de3eloping anemia2 !reoperati3e 5B5 Treatment with a :nR/ agonist for " months preoperati3ely can impro3e hematocrit and decrease need for (lood transfusions intraoperati3ely.

Routine 5B5 in symptomatic patients or those reporting persistent hea3y (leeding is warranted.

Bi(liography Duehold M0 et al. Magnetic resonance imaging and trans3aginal ultrasonography for the diagnosis of adenomyosis. ertil 6teril. +##*DEC2%FF$%GH. Mc&lin TW0 et al. Adenomyosis of the uterus. B(stet :ynecol Annu. *GEHD"2H+%$ HH*. ?ercellini !0 et al. Adenomyosis at hysterectomy2 A study on fre;uency distri(ution and patient characteristics. /uman Reprod. *GG%D*#2**C#$**C+. Wood 5. 6urgical and medical treatment of adenomyosis. /um Reprod 1pdate. *GGFDH@HA2"+"$""C. Miscellaneous A((re3iations I :nR/J:onadotropin-releasing hormone I B5!JBral contracepti3e pill I !'DJ!el3ic inflammatory disease I T?6JTrans3aginal ultrasound 5odes '5DG-5M C*E.#2 I Adenomyosis I &ndometriosis2 $ 5er3i) $ 'nternal $ Myometrium !atient Teaching !el3ic !ain !atient &ducation !amphlet0 American 5ollege of B(stetricians and :ynecologists0 January +##C